This form is primarily for new participants in this group, but may be used by those re-enrolling if a preprinted Illinois 4-H
Individual Re-Enrollment Form is not available. Each youth participant must enroll in at least one (1) project yearly.
See project list if attached or check with group’s leader to ensure project enrollment.
Group Name

Member

Youth Leader

Member and Youth Leader

New

Re-enroll

Male

Female Yrs in 4-H (including this year)
Date of Birth / / Grade K, 1-12; PO (Post high school); NO (not in school)
First Name
Street Address
MI Last Name
PO Box City Zip Code
County of Residence
Phone: ( ) -
E-mail
Type:

Home Phone

Cell Phone
Parent Information

Address Same as Member (if same as member, no need to fill in address)
Mother - First Name MI Last Name
Street Address
( )
Telephone
-
PO Box City
( ) -
Alternate Phone
Would you like to receive 4-H program mailings?
E-mail

Yes

No
Zip Code
Parent Information

Address Same as Member (if same as member, no need to fill in address)
Father - First Name
Street Address
( )
Telephone
-
PO Box City
E-mail
MI Last Name
( ) -
Alternate Phone
Would you like to receive 4-H program mailings?

Yes

No
Zip Code
Continued on back
__________________________________________________________________________________________________
Issued in furtherance of Cooperative Extension Work, Acts of May and June 30, 1914, in cooperation with the U.S. Department of Agriculture,
Robert Hoeft, Interim Director, University of Illinois Extension, University of Illinois at Urbana-Champaign. University of Illinois Extension provides equal opportunities in programs and employment. The 4-H Name and Emblem are Protected Under 18 U.S.C. 707

Ethnicity Residence
Hispanic or Latino

Yes

No
Race : (select one or more)
 American Indian or Alaskan Native

Asian
 Black or African American
 Native Hawaiian or Pacific Islander
 White
Military Affiliation

None
 Air Force
 Air National Guard

Air Force Reserve

Army
 Army National Guard
 Army Reserve

Marine Corp
 Farm (where income is earned farming)

Rural/Small Town (under 10,000)
 Medium Town (10,000-50,000)
 Suburb greater than 50,000
 City greater than 50,000

Navy
 Navy Reserve
 Coast Guard

Coast Guard Reserve
 Marine Corps Reserve
Parent/Guardian Photo/Video/Audio Release

Yes

No I grant the University of Illinois Extension 4-H Youth Program, irrevocable permission to record and/or disclose my child's identity, image, and voice arising out of documenting 4-H youth programs and to use, reproduce and distribute such in whole or in part in video and/or sound recordings, films, photographs, transparencies, webpages, social media, local news media or any other media for any purpose on behalf of the University and Extension without compensations to me and without any right for me to inspect or approve of the finished photograph, video, or audio recordings or other recordings.
Signature Date ___________________
Foundation Mailing Lists
 Yes  No I would like information on the county-level Foundation and how it supports the 4-H program.

Yes

No I would like information on the Illinois 4-H Foundation and how it supports the 4-H program.
4-H Youth Behavior Guidelines: All youth who participate in Illinois 4-H Youth Development programs, which are planned, conducted, and supervised by University of Illinois Extension, are responsible for their own conduct. Youth participating in 4-H programs are expected to demonstrate the character traits of trustworthiness, respect, responsibility, fairness, caring, and citizenship. Specifically, 4-H youth are expected to abide by the following behavior guidelines:
1. Be courteous and respect others.
2. Obey all the laws of the locality, state, and nation and University of Illinois and Extension policies and guideline as well as 4-H Program Guidelines and those of the local club/group.
3. Treat all people fairly and animals humanely.
4. Respect the property of others.
5. Respect the authority of adult or youth volunteers, paid Extension staff, and others in leadership roles.
6. Use appropriate language and wear acceptable clothing at 4-H activities and events.
7. Show kindness to others and give assistance when needed.
8. Be honest and honor commitments.
9. Strive for personal best and keep trying to improve.
10. Accept responsibility for personal choices.
We understand and accept the responsibility for following the 4-H Youth Behavior Guidelines. We further understand that failure to do so may result in disciplinary action and forfeiture of participation privileges.
Signature of Participant
Office Use Only
Signature of Parent/Guardian Date
 Paid
 Paid in another county
 EFNEP/FNP Exempt
 No Opt Out
 Cash
 Check No.
 Debit Card
 Credit Card
 Scholarship
University of Illinois • U.S. Department of Agriculture • Local Extension Councils Cooperating
University of Illinois Extension provides equal opportunities in programs and employment.
The 4-H Name and Emblem are Protected Under 18 U.S.C. 707.
Revised 8/2012